Until recently, American society was uncritically committed to prolonging the life of all citizens. Insurance payments influenced physicians through direct financial incentives and through the indirect incentive of societal approbation. Insurance companies, as powerful representatives of society, clearly approved of the prolongation of life with advanced life-support technologies. The insurers ratified the life-at-any-cost mentality that physicians were adopting in the 1960s and 1970s. This is not surprising because the dominant insurers of this period—Blue Cross and Blue Shield— were controlled by physicians and hospitals.

This mentality lead to striking increases in the cost of medical care. Employers, who buy most health insurance, and government, which pays for Medicare and Medicaid, became concerned with resource allocation. Resources expended on supporting the life of a patient are not available for other objectives, such as education or preventive medical care. [Murphy DJ, Matchar DB. Life-sustaining therapy: a model for appropriate use. JAMA. 1990;264:2103–2108.] The enactment of the Medicare prospective payment system is one manifestation of this concern. Implicit in the prospective payment system is a repudiation of the life-at-all-cost signal sent by the previous cost-based reimbursement system. [Veatch RM. Justice and the economics of terminal illness. Hastings Cent Rep. 1988;18:34.]

Societal interests have become more complicated as antiabortion forces have sought legislation that demands that the state favor life under all circumstances. Although intended to limit abortions, such statutory presumptions can also be read as limiting termination of life-support decisions. This is at issue in the Cruzan decision by the Missouri Supreme Court. The court held that its refusal of an order to terminate life support for an incompetent person was mandated by a pro-life statutory provision in the state’s antiabortion law.